Provider Demographics
NPI:1427419167
Name:DYNAMIC SPORTS MEDICINE AND PAIN SOLUTIONS PLLC
Entity type:Organization
Organization Name:DYNAMIC SPORTS MEDICINE AND PAIN SOLUTIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICAL
Authorized Official - Middle Name:SAMUELSON
Authorized Official - Last Name:DUVALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-602-5578
Mailing Address - Street 1:41922 N MILL DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-1850
Mailing Address - Country:US
Mailing Address - Phone:210-602-5578
Mailing Address - Fax:
Practice Address - Street 1:7830 W GRAND PKWY S
Practice Address - Street 2:SUITE 150
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-5816
Practice Address - Country:US
Practice Address - Phone:832-302-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0169208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1669600324OtherNPI